Failure to Timely Report and Investigate Resident-on-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to promptly report and thoroughly investigate an allegation of physical abuse between two residents. On 1/27/2026 at 10:37 AM, one resident (R131) was observed sitting in bed, holding his left shoulder and wincing in pain, and reported experiencing severe left shoulder pain that began on 1/18/2026 after being physically attacked by another resident (R200). R131 stated that R200 suddenly charged at him, grabbed him, and placed both arms around his upper torso, putting him in a headlock. The facility’s Administrator/Abuse Coordinator (V1) acknowledged that he had reviewed security camera footage from 1/18/2026 and was aware of the incident that same night. Despite this awareness, V1 stated he did not report the incident to the Illinois Department of Public Health (IDPH) at that time because he did not believe it met the definition of abuse, citing the absence of serious injury, bodily harm, or psychosocial effects. The incident was not reported to IDPH until 1/27/2026, as confirmed by a fax confirmation sheet showing the initial report was sent at 2:59 PM with a documented occurrence date of 1/18/2026 and categorized as resident abuse. The report also indicated that a thorough investigation was to be conducted, demonstrating that the investigation was initiated nine days after the incident. This delay and failure to immediately initiate an investigation conflicted with the facility’s Abuse and Retaliation Prevention and Reporting policy, which requires that all incidents be documented and that any incident or allegation involving abuse result in an investigation initiated by the administrator or designee upon learning of the report, including interviews of the reporter, individuals with direct knowledge, and the resident, as well as review of written statements and pertinent medical records or documents.
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